Embassy of Tunkhannock

In the surveyor’s words

From the most serious findings on record at Embassy of Tunkhannock, in the surveyor’s own words.

• Immediate jeopardy, patternF760Apr 9, 2026

  Based on a review of clinical records, select facility policies, documentation provided by the facility, observations, and staff interviews, it was determined the facility failed to ensure residents were free of significant medication errors and failed to implement effective procedures to accurately identify residents prior to medication administration. This failure resulted in an Immediate Jeopardy situation when a nurse administered a narcotic medication (morphine sulfate) prescribed for Resident 50 to Resident 51, causing profound bradycardia (abnormally slow heart rate) requiring emergency transfer to the hospital and administration of naloxone (a medication that reverses the effects of opioid overdose) on two occasions. […]

• Actual harm, isolatedF689Aug 19, 2026

  Based on a review of select facility policies, clinical records, facility investigation documentation, and staff interviews, it was determined the facility failed to implement required fall prevention interventions for one resident assessed as high risk for falls (Resident 1), and failed to ensure the correct level of assistance was documented and consistently provided for one of 10 residents (Resident 2) sampled. These failures resulted in Resident 1 and Resident 2 sustaining falls that caused harm with major injury.Findings include: A review of the Fall Prevention and Management Policy last reviewed by the facility on January 23, 2026, revealed each resident will be assessed for fall risk on admission, quarterly, and after any fall happens. […]

• Actual harm, isolatedF658Apr 9, 2026

  Based on review of clinical records, facility provided investigative documentation, select facility policies, applicable state professional nursing standards, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of practice, resulting in actual harm. The facility failed to ensure a licensed nurse correctly identified a resident prior to medication administration for one of 11 residents reviewed (Resident 51). […]

• Actual harm, isolatedF689Dec 30, 2024

  Based on a review of clinical records, select resident investigative reports, and staff interview, it was determined the facility failed to consistently provide sufficient staff assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls with serious injuries for one resident out of 7 sampled residents. (Resident 1). Findings include: A review of clinical records revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include muscles weakness, congestive heart failure (condition that occurs when the heart can't pump enough blood to meet the body's needs) and generalized anxiety disorder (condition that involves excessive and persistent worrying that interferes with daily life). […]

• Actual harm, isolatedF686May 21, 2024

  Based on observation, a review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized resident care, consistent with professional standards of practice, to prevent the development of an avoidable mucosal membrane pressure injury, with pain for one resident out of two sampled residents (Resident 23). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. […]